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Journal of Nutrition & Food Sciences DOI: 10.4172/2155-9600.1000724

ciences
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ISSN: 2155-9600

Research Article Open Access

Effects of Tea Consumption on Measures of Cardiovascular Disease: A

Systematic Review of Meta-Analysis Studies and Randomised Controlled Trials
Chris Etheridge1, Tim Bond2 and Emma Derbyshire3*
1
Integrated Cancer Healthcare, UK
2
Tea Advisory Panel, UK
3
Nutritional Insight Ltd, Surrey, KT17 2AA, United Kingdom

Abstract
Background: The results of meta-analysis studies and randomised controlled trials (RCTs) published in the
last 10 years were collated and the effect of tea consumption on measures of cardiovascular disease (CVD) was
considered.
Methods: PubMed was systematically searched for relevant meta-analysis papers and RCTs. Inclusion and
exclusion of studies, data extraction, and quality assessment were conducted according to the PRISMA statement.
The Jadad criteria was applied to decipher the quality of RCTs.
Results: Findings from 19 meta-analysis and 23 randomised controlled trials (n=1,422 participants) were
evaluated. Clear evidence was found for blood pressure where 4 to 5 cups of black or green tea daily related to risk
reduction. Moderate evidence was of a positive effect of green tea and its associated catechins on total and low-
density lipoprotein (LDL) reduction. Growing evidence indicates that tea drinking could protect vascular health and
reduce inflammation. A wider range of tea forms (chamomile tea, goishi tea, hibiscus tea, sour tea, rooibos tea) are
increasingly being studied and also appear to have potentially favourable effects on markers of CVD.
Conclusion: Tea drinking appears to play a significant role in blood pressure reduction, particularly amongst
those with prehypertension or hypertension. Green tea has beneficial effects on total and LDL cholesterol reduction.
Tea drinking in general appears to aid vascular function and the reduction of inflammation. Ongoing long-term trials
are needed especially in relation to other tea forms alongside black and green tea.

Keywords: Cardiovascular disease; Blood pressure; Hypertension;
Inflammation; Green tea
Introduction
Originating in China, tea (Camellia sinensis, Theaceae) and the
planting of tea spread in popularity and today more than 160 countries
in the world are accustomed to tea drinking [1,2]. This makes the
drinking of tea one of the most widely consumed beverages globally [2].
Tea has long been regarded for its health promoting properties - helping
to maintain cardiovascular and metabolic health since ancient times [3].
Epidemiological data has also discovered that black and green tea may
reduce coronary heart disease and stroke risk by between 10 and 20 per
cent, respectively [4].
Black (aerated), green (non-aerated) and oolong (partially
aerated) tea are three of the most popular tea forms consumed today
– all produced from the leaves of the plant Camellia sinensis [5].
These have been found to possess antioxidative, anti-inflammatory,
antihypertensive and cholesterol-lowering properties [5]. In particular,
non-caffeine components - namely the flavonoids are thought to
contribute to cardiovascular (CV) health [6]. Common bioactive
compounds found in green teas include flavan-3-ols (catechins) (also
called flavanols), proanthocyanidins (tannins) and flavonols. Black tea
is a good provider of theaflavins and thearubigins whilst herbal teas can
contain a diverse range of polyphenols [7].
CVD is a well-known global healthcare burden. It is thought that
CVD risk may be lowered by adjusting modifiable risk factors such as
the diet, and this includes habitual intakes of tea [8]. To define, CVD
encompasses a range of disorders of the heart and blood vessels (Table
1). More people die annually from CVDs than from any other cause
making this the number one cause of death globally. In 2015 17.7 million
people died from CVDs which was equivalent to around a third (31%)
of all global deaths [9]. In the UK it has been projected that programmes
which could reduce CV events by just 1 per cent would contribute to
health service savings worth at least £30 million ($48 million) compared
to if no intervention was put into place [10].
A large body of observational evidence has made links between tea
consumption and reduced risk of heart disease [11] alongside other
factors such as reduced stroke risk, particularly ischaemic stroke [12].
Unfortunately, observational evidence can be confounded by lifestyle
and dietary factors [13]. A number of new randomised controlled trials
(RCTs) have been published within this field in recent years. RCTs
are regarded as the gold-standard when determining whether cause-
and-effect relationships exist between interventions and predefined
outcomes [14].
Considering this, the present review article aims to collate evidence
from both meta-analysis articles and RCTs to determine whether tea
consumption has any effect on risk factors and pathways linked to the
development of CVD.
*Corresponding author: Emma Derbyshire, Nutritional Insight Ltd, KT17 2AA,
United Kingdom, Tel: (+44) 0208 393 0500, E-mail: emma@nutritional-insight.co.uk
Received July 18, 2018; Accepted August 30, 2018; Published September 12,
2018
Citation: Etheridge C, Bond T, Derbyshire E (2018) Effects of Tea Consumption on
Measures of Cardiovascular Disease: A Systematic Review of Meta-Analysis Studies
and Randomised Controlled Trials. J Nutr Food Sci 8: 724. doi: 10.4172/2155-
9600.1000724
Copyright: © 2018 Etheridge C, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original
author and source are credited.

J Nutr Food Sci, an open access journal

ISSN: 2155-9600 Volume 8 • Issue 5 • 1000724
Citation: Etheridge C, Bond T, Derbyshire E (2018) Effects of Tea Consumption on Measures of Cardiovascular Disease: A Systematic Review of
Meta-Analysis Studies and Randomised Controlled Trials. J Nutr Food Sci 8: 724. doi: 10.4172/2155-9600.1000724

Page 2 of 9

Methods design, geographic location, demographic and health characteristics

Eligibility criteria/study selection
A PubMed search was undertaken to identify relevant meta-
analysis papers and RCTs using the selection filter. Filters were applied
to identify English-language human trial published in the last 10 years
to include most recent evidence.
Search terms applied were: tea [TIAB] AND ‘cardiovascular
function’, blood pressure, ‘cholesterol’, ‘lipid profile’, ‘inflammation’
and ‘c-reactive protein; CRP’. The same search terms were applied
when first identifying meta-analysis papers (meta-analysis papers of
RCTs and prospective cohorts) and then separate RCTs. The last search
to identify included studies was undertaken on February 28th, 2018.
Quality/risk of bias assessment
of the study population (e.g. age, sex, presence of obesity or a chronic
disease, body mass index), sample size, intervention duration, tea type,
amount ingested, a description of the control product, and outcomes
measured. Relevant data extracted from the studies included volume
of tea ingested per day (cups or ml), information on randomisation
method, double-blinding and withdrawal rates. This information was
used to develop quality scores for each study based on Jadad criteria.
Results
The PubMed search identified 315 papers and after an adjustment
for replica papers 292 articles were further examined for assessment. Of
these, a further 161 papers were discarded after reviewing the abstracts
as they did not meet the inclusion criteria. This left 131 full-text articles
to be reviewed.

The Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) statement was followed [15]. There were no
exclusions based on age, ethnicity or health status of the baseline study
population. The quality of RCTs was evaluated using the Jadad scale
(Table 2) [16]. Quality scores were ranked between 1 and 5 with higher
scores being indicative of higher quality.
For RCTs specifically these were included if the following criteria
were met:
(1) the trial was randomised and involved human subjects;
(2) the trial was a controlled intervention providing tea in beverage
form and a control beverage;
(3) the trial specified the form and amount of tea ingested – all
types of tea were included – black, green and herbals using the
generic search term ‘tea’;
(4) the trial studied the specified measures of cardiovascular
disease (vascular function, blood pressure, cholesterol, lipid
profile, inflammation, CRP)
(5) the trial did not use tea extracts, powders, supplements, gargles
or combined multi-component interventions (Figure 1).
Data extraction/collection
Key findings were collated from meta-analysis papers and
summarised in table form so these could be compared and contrasted.
This included data on the type and amount of tea ingestion where
specified. The methodology developed by the Joanna Briggs Institute
was read with interest and largely applied when developing the review
methodology [17,18].
For RCTs, all eligible trials were reviewed and relevant data were
extracted, including: name of the first author, publication year, study
Of these an additional 44 were excluded as these used irrelevant
interventions including tea gargles, powders or extracts. Twenty-
five were discarded as these focused on tea components such as
epigallocatechin gallate rather than tea as a drink per se. A further
seven studied health outcomes that were not aligned with the
specified criteria, eight applied multi-component interventions e.g. tea
consumption along with exercise or supplements and four were not
RCTs.
Subsequently a total of 19 meta-analysis papers (including those
collating evidence from prospective cohorts and trials) and 23 RCTs
were identified (Figure 1). Of these 16 meta-analysis papers focused
on tea consumption in relation to blood pressure, cholesterol or lipid
profile and 14 trials also investigated tea consumption in relation to
these specific parameters. Remaining meta-analysis papers and RCTs
looked at tea consumption in relation to vascular function of markers
of inflammation, including CRP.
Blood pressure
There is a large body of evidence looking at inter-relationships
between tea and blood pressure. This is reflected by the number of
meta-analysis papers published (Table 3). Eight meta-analysis papers
were identified [8,19-25]. Of these, regular consumption of black and
green tea was associated with reductions in blood pressure which could
be important for CV health at population level [8,20]. Effects were
most prominent in adults with blood pressure in pre-hypertensive and
hypertensive ranges (19) and long-term black and green tea drinkers
consuming this for more than 12 weeks [21]. One meta-analysis linked
(Hibiscus sabdariffa L.) consumption to reduced blood pressure [25,26].
As shown in Table 4 seven separate RCTs looked at the effects of
tea drinking on blood pressure [27-33]. In these trials participants were
typically asked to consume 2 to 3 cups of tea daily. In one 8-day trial
black tea consumption (2 cups daily) significantly reduced systolic and

Disorder What this is Outcomes studied in the present review

Cerebrovascular disease
Congenital heart disease
Coronary heart disease
Deep vein thrombosis and
pulmonary embolism
Peripheral arterial disease
Rheumatic heart disease
Disease of the blood vessels supplying the brain. The present review focused solely on tea consumption in relation to:
Malformations of heart structure - exists at birth. o Cardiovascular function/health
o Blood pressure
Disease of the blood vessels supplying the heart muscle.
o Cholesterol levels
Blood clots in the leg veins, which can dislodge and move to the o Lipid profile
heart and lungs. o Inflammation
Disease of blood vessels supplying the arms and legs. o c-reactive protein levels.
Damage to the heart muscle and heart valves from rheumatic
fever, caused by streptococcal bacteria.

Source: WHO (2017) [9].

Table 1: Disorders categorised as cardiovascular diseases.

J Nutr Food Sci, an open access journal

ISSN: 2155-9600 Volume 8 • Issue 5 • 1000724
Citation: Etheridge C, Bond T, Derbyshire E (2018) Effects of Tea Consumption on Measures of Cardiovascular Disease: A Systematic Review of
Meta-Analysis Studies and Randomised Controlled Trials. J Nutr Food Sci 8: 724. doi: 10.4172/2155-9600.1000724

Page 3 of 9

diastolic blood pressure and prevented rises in blood pressure after

the ingestion of a fat loaded meal [28]. Australian research showed
that drinking 3 cups black tea daily over 6 months (supplying ≈ 429
mg polyphenols) reduced systolic and diastolic blood pressure by 2-3
mmHg [31]. Another trial by the same research team showed that
similar amounts of tea led to sustained blood pressure lowering effects
over 6-months which included a 10 per cent variation in blood pressure
at night time [29].
Three RCTs have studied the effects of sour tea [27,30,33]. This was
found to improve systolic blood pressure in healthy adult men [27] and
reduce overall blood pressure in mildly hypertensive type 2 diabetic
adults [30,33]. One trial found that 3 cups (240 ml) of brewed hibiscus
tea daily significantly lowered blood pressure amongst pre- and mildly
hypertensive adults [32]. Six out of the 7 trials (Table 4) had a Jadad
score above 3 indicating that quality was above average.
Cholesterol and lipids
Eight meta-analysis articles studied the effects of tea consumption
on cholesterol and lipid levels [8,22,23,34-38]. A large body of these
suggest that green tea and its associated catechins could contribute
to reductions in total and low-density lipoprotein (LDL) cholesterol
[22,23,36-38]. Another investigation where black and green tea were
analysed together showed favourable effects on LDL cholesterol [8]
Figure 1: Study selection process.
though the inclusion of green tea could have driven this. Meta-analytical

Method of randomisation Blinding Method of blinding Withdrawal and dropout

Publication Randomisation
Kafeshani et al. [27]
Grassi et al. [28]
Hodgson et al. [29]
Hodgson et al. [31]
Mozaffari-Khosravi et al.
[30]
McKay et al. [32]
Mozaffari-Khosravi et al.
[33]
Ishida et al. [39]
Ashigai et al. [40]
Rafraf et al. [41]
Troup et al. [42]
Bohn et al. [6]
Koutelidakis et al. [43]
Bahorun et al. [44]
Grassi et al. [48]
Schreuder et al. [49]
Basu et al. [50]
Sone et al. [51]
Persson et al. [52]
Grassi et al. [53]
Maghsoumi-Norouzabad
et al.
Mahmoud et al. [55]
Koutelidakis et al. [43] *
Bahorun et al. [56]
Note: Total quality assessment score for which scores range between 1 and 5: with 1 being the lowest quality and 5 being the highest quality. *Included twice as markers
of lipid metabolism and inflammation were recorded.
Total score
described & appropriate mentioned described and appropriate of subjects provided
Blood pressure
1 1 1 1 1 5
1 1 0 0 1 3
1 1 1 0 1 4
1 0 1 0 0 2
1 1 0 1 1 4
1 1 1 1 1 5
1 1 0 0 1 3
Cholesterol & lipid profile
1 0 1 0 1 3
1 1 1 1 1 5
1 1 1 0 1 4
1 1 0 0 1 3
1 1 1 1 1 5
1 1 1 0 1 4
1 1 0 0 1 3
Vascular function
1 0 1 0 1 3
1 0 1 0 1 3
1 1 1 1 1 5
1 1 1 1 1 5
1 0 0 0 0 1
1 0 1 1 1 4
Inflammation
1 0 0 0 1 2
1 0 0 0 0 1
1 1 1 0 1 4
1 0 0 0 1 2
Table 2: Quality assessment used to assess RCTs identified in the systematic review.

J Nutr Food Sci, an open access journal

ISSN: 2155-9600 Volume 8 • Issue 5 • 1000724
Citation: Etheridge C, Bond T, Derbyshire E (2018) Effects of Tea Consumption on Measures of Cardiovascular Disease: A Systematic Review of
Meta-Analysis Studies and Randomised Controlled Trials. J Nutr Food Sci 8: 724. doi: 10.4172/2155-9600.1000724

Page 4 of 9

Health outcome Strength and amount of evidence from human studies References
Consumption of green or black tea can reduce BP in individuals within pre-hypertensive and hypertensive
Yarmolinsky et al. [19]
ranges.
Drinking 4-5 cups tea daily can significantly reduce systolic and diastolic BP. Greyling et al. [20]
Long-term tea ingestion of tea for more than 12 weeks can significantly reduce systolic and diastolic BP. Liu et al. [21]
Blood pressure
Green tea intake and its catechins can significantly reduce systolic BP. Effects may be greater in those with Khalesi S et al. [22]; Onakpoya I
systolic BP ≥ 130 mm Hg. et al. [23]; Peng et al. [24]
Green and black tea types analysed together (Cochrane review) show favourable effects on BP. Hartley et al. [8]
Sour tea (Hibiscus sabdariffa L.) can significantly reduce systolic and diastolic BP. Serban et al. [25]
Black tea can significantly reduce LDL cholesterol concentration. Subgroup analysis shows lowering effects
Zhao et al. [34]
tend to be more effective in subjects with higher cardiovascular risk.
Black tea might not have beneficial effects on concentrations of total cholesterol, HDL and LDL. Wang et al. [35]
Cholesterol and lipids Yuan et al. [36]; Khalesi S et al.
Green tea intake and catechins results in significant reductions in total cholesterol, and LDL cholesterol. [6]; Onakpoya I et al. [7]; Kim et
al. [37]; Zheng et al. [38]
Green and black tea types when analysed together (Cochrane review) show favourable effects on LDL
Hartley et al. [9]
cholesterol.
Drinking ≥4 cups or 1-3 cups of green tea per day can reduce risk of myocardial infarction and stroke compared
to those drinking <1 cup/day. Those drinking ≥10 cups/day of green tea daily had lower LDL compared to those Pang et al. [45]
drinking <3 cups/day.
Cardiovascular function
Green tea consumption was significantly inversely associated with CVD and all-cause mortality. Tang et al. [46]
Tea enhances endothelial-dependent vasodilation. This may provide a mechanistic explanation for the reduced
Ras et al. [47]
risk of cardiovascular events and stroke observed amongst tea drinkers.
Abbrevations: BP: Blood Pressure, CVD: Cardiovascular Disease, HDL: High-Density Lipoprotein, LDL: Low Density Lipoprotein.
Table 3: Tea and cardiovascular disease: meta-analysis papers.

Population (age, sex, Intervention (duration, type of Outcomes

Study (Location)
health)
Kafeshani et al.
n=54 healthy adult men
[27] Iran
Grassi et al. [28] n=19 healthy adults 18-75
Italy years.
n=111 men and women with
Hodgson et al. [29]
systolic BP between 115 and
Australia
150 mm Hg at screening.
Mozaffari-Khosravi n=100 mildly hypertensive
et al. [30] Iran patients with diabetes.
n=95 men and women 35 to
75 years, regular tea drinkers,
Hodgson et al. [31]
BMI 19 to 35, daytime
Australia
ambulatory SBP between 115
and 150 mm Hg at screening.
n=65 pre- and mildly
hypertensive adults, age
McKay et al. [32]
30-70 y, not taking blood
USA
pressure (BP)-lowering
medications,
n=60 diabetic patients with
mild hypertension, without
Mozaffari-Khosravi
taking antihypertensive
et al. [33] Iran
or antihyperlipidaemic
medicines.
Study Design Findings
tea and amount ingested) measured
Blood pressure
6-month randomized, Received 450 mg (about 2 Sour tea supplementation led to
DB, placebo- cups/d) green tea or sour tea BP decreased systolic BP in healthy men
controlled trial. and one placebo group. compared with the placebo.
8-day randomized,
Black tea decreased systolic and
DB, controlled,
Systolic, diastolic diastolic BP and prevented BP
cross-over design 2 cups/d of black tea (129 mg
BP, refraction and increase after a fat load (p<0.0001).
trial. Measurements flavonoids) or placebo.
stiffness index. Regular consumption of black tea may
in a fasted state and
be relevant for CV protection.
after a fat load.
Across the 3 time points, tea,
6-month randomized, 3 cups/d of either powdered
compared with the control, resulted in
controlled, DB black tea solids (tea) or a
24-h ambulatory BP. lower rates of systolic (p=0.0045) and
parallel-designed flavonoid-free caffeine-matched
diastolic (p=0.016) BP variation by
trial. beverage (control).
~10% during night-time.
Mildly hypertensive type 2 diabetic
Drank sour tea and green tea individuals who drink three glasses
4-week randomized
infusion, respectively, three Systolic, diastolic BP. of green or sour tea daily for 4 weeks
clinical trial.
times a day 2 hr after each meal. show significant decreased systolic
and diastolic BP.
Regular consumption of 3 cups/d
6-month randomized of black tea over 6 months,
placebo-controlled supplying approximately 429 mg/d of
3 cups/d regular black tea. Ambulatory BP.
DB 6-month parallel polyphenols, resulted in lower systolic
designed trial. and diastolic BP of between 2 and 3
mm Hg.
Daily consumption of hibiscus
6-week randomized, tea lowers BP in pre- and mildly
DB placebo- 3 cups/d (240-mL) of brewed hypertensive adults and may prove
Systolic, diastolic BP.
controlled clinical hibiscus tea or placebo beverage an effective component of the dietary
trial. changes recommended for people
with these conditions.
Consuming sour tea infusions
Drank 2 cups/d of black tea or
1-month randomized had positive effects on BP in
sour tea infusions (240 ml). Systolic, diastolic BP.
trial. type II diabetic patients with mild
hypertension.
Cholesterol and lipid profile/distribution

J Nutr Food Sci, an open access journal

ISSN: 2155-9600 Volume 8 • Issue 5 • 1000724
Citation: Etheridge C, Bond T, Derbyshire E (2018) Effects of Tea Consumption on Measures of Cardiovascular Disease: A Systematic Review of
Meta-Analysis Studies and Randomised Controlled Trials. J Nutr Food Sci 8: 724. doi: 10.4172/2155-9600.1000724

Page 5 of 9

12-week Goishi tea group daily Goishi tea polyphenols tended to

n=77 adults with LDL
Ishida et al. [39]
cholesterol (CHO) ≧120 mg/
Japan
mL.
Two 10-day periods.
Ashigai et al. [40] n=24 healthy males and
Japan females, aged 20 to 64 years
Placebo-Controlled, control beverage without BTP 3
old, were enrolled.
DB crossover Study.
Rafraf et al. [41] n=64 adults with T2DM 30
Iran and 60 years.
n=57 borderline
Troup et al. [42]
hypercholesterolemic
USA
individuals.
6-month randomized
n=111 regular tea drinking
Bohn et al. [6]
men and women (35-75
Norway
years)
Koutelidakis et al. n=43 patients with coronary
[43] Greece artery disease
randomized, DB consumption (122 mg of
placebo-controlled polyphenols) and the placebo
clinical study. group (12.2 mg of polyphenols).
Drank either a beverage
Randomized, containing 55 mg BTP or a
Faecal lipid excretion.
times a day for 10 d.
8-week SB Consumed 3 cups chamomile
randomized tea (3 g/150 mL hot water)
controlled clinical immediately after meals or
trial. control water.
Diet controlled 5 cups per day of black tea
randomized trial. alongside a controlled low-
Two 4-week flavonoid diet plus or tea-like
treatment periods. placebo.
3 cups per day of powdered
black tea solids (tea) or a
controlled DB
flavonoid-free flavour- and
parallel-designed
caffeine-matched placebo
trial.
(control).
5-hours post
Consumed breakfast and 330
ingestion.
ml of green tea (4.5 g /330 ml,
Randomized
providing approximately 400 mg
controlled, parallel
catechins) or water.
design.
increase HDL and suppress the
Blood lipid profiles.
elevation of triglycerides particularly
amongst those with a BMI <25 kg/m2.
Total lipid excretion increased from
5.51 ± 1.73 to 6.87 ± 1.91 g/3 d after
BTP intake in comparison with intake
of the control beverage. These results
indicated that BTP increased lipid
excretion.
Chamomile tea significantly
Fasting blood decreased total cholesterol (p=0.001),
glycaemic and lipid triglyceride (p<0.001), and low-density
profiles. lipoprotein cholesterol (p=0.05)
compared with control group.
Total cholesterol,
HDL, LDL, No results were statistically or
triglycerides, LDL/ clinically significant.
HDL ratio.
Weight, waist- and Short-term regular ingestion of black
hip-circumference, tea over 3 months can improve
endothelial function, body fat distribution, compared to a
plasma biomarkers. caffeine-matched control beverage.
Total cholesterol,
LDL, HDL,
Serum triglycerides levels significantly
triglycerides, glucose,
increased 3 h after breakfast with
CRP, uric acid and
water (p=0.031), but not after
pancreatic lipase
breakfast with tea.
levels.

Induced, a significant decrease in

triglyceride levels (35.8%; p<0.01),
12-week randomized 3 x 200 ml cups of black tea HDL/LDL cholesterol, a significant decrease in LDL/HDL
Bahorun et al. [44]
n=77 normal population controlled clinical infusate/day for 12 weeks or a triglycerides, plasma cholesterol ratio (16.6%;
Mauritius
trial hot water control beverage. antioxidants. p<0.05) and a non-significant increase
in HDL plasma cholesterol levels
(20.3%).
Cardiovascular function
Black tea ingestion increased
8-day randomized, Black tea (150 mg polyphenols) functionally active CACs and FMD.
Grassi et al. [48] n=19 never-treated
DB controlled, cross- or a placebo twice a day for eight CACs, FMD Fat challenge decreased FMD, while
Italy hypertensive patients.
over study. days. tea consumption counteracted FMD
impairment (p<0.0001).
Tea consumption resulted in an
Schreuder et al. 7-day randomized, 3 cups per day of black tea or Brachial artery immediate increase in FMD% whilst
n=20 healthy subjects
[49] Netherlands crossover study. abstinence from tea. endothelial FMD. no such change occurred after
ingestion of hot water.
Randomly assigned to receive Green tea significantly reduced
n=41 adults age 42.5 years, green tea (4 cups/d), green tea Markers of MetS plasma serum amyloid alpha, an
Basu et al. [50] 8-week randomized
body mass index 36.1 kg/m extract (2 capsules and 4 cups and cardiovascular independent cardiovascular disease
USA controlled trial.
(2)] water/d), or no treatment (4 cups health. risk factor, in obese subjects with
water/d) metabolic syndrome.
There were no significant differences
Green tea was either high Changes in the between the high-and low catechin
Sone et al. [51] 9-week randomized
n=51 healthy subjects catechin (400 mg/day) or low adiponectin levels groups with respect to changes in the
Japan trial.
catechin (100 mg/day). and CVD risk factors. serum adiponectin level and any CV
risk factors.
3 hr randomized, Green tea and Rooibos tea may
Persson et al. [52] n=17 healthy adults aged 20- 400 ml green tea, black tea or ACE activity, NO
three-phase, have cardiovascular effects through
Sweden 31 years. Rooibos tea. concentration.
crossover study inhibition of ACE activity.
5 1-week periods. Black tea ingestion dose dependently
Twice daily intake of black tea (0,
Grassi et al. [53] Randomized, DB improved FMD and decreased
n=19 healthy men. 100, 200, 400 and 800 mg tea FMD.
Italy controlled, cross- peripheral arterial stiffness in healthy
flavonoids/day)
over design volunteers.
Inflammation
Received daily 3 cups/d Burdock Burdock root tea significantly
root tea (each cup containing decreased the levels of serum IL-6,
Maghsoumi- n=36 patients (10 men and 26 2 g/150 mL boiled water) half- hs-CRP and malondialdehyde, while
42-day randomized Inflammatory
Norouzabad L et women) aged 50-70 years old hour after the meal. The control the levels of serum TAC and activities
parallel trial. markers.
al. [54] Iran with knee osteoarthritis group received three cups of SOD were significantly increased.
containing 150 cc boiled water GPX activities increased but not
daily. significantly.

J Nutr Food Sci, an open access journal

ISSN: 2155-9600 Volume 8 • Issue 5 • 1000724
Citation: Etheridge C, Bond T, Derbyshire E (2018) Effects of Tea Consumption on Measures of Cardiovascular Disease: A Systematic Review of
Meta-Analysis Studies and Randomised Controlled Trials. J Nutr Food Sci 8: 724. doi: 10.4172/2155-9600.1000724

Page 6 of 9

Tea consumption correlated with

increased regulatory T cells CD3+
3 cups/d (600 mL) of black tea CD4+ CD25+ FOXP3, CD3+ CD4+
Intracellular
Mahmoud et al. 12-week randomized per day; and a Low Intake (LI) IL-10+ cells (an immunosuppressive
n=30 patients with T2DM cytokine expression,
[55] Kuwait trial. group, administered 1 cup (200 phenotype), reduced (pro-
regulatory T cells.
mL) per day, inflammatory) CD3+ CD4+ IL-17+
cells and reduced Th1-associated
CD3+ CD4+ IFN-Υ+ cells.
330 ml water or tea (4.5 g Biomarkers Tea consumption did not affect
Randomized
Koutelidakis et al. green tea/330 ml, providing measured hourly selected biomarkers at any
n=43 with CAD controlled, parallel
[43] Greece approximately 400 mg up to 5 hrs post postprandial time point in patients with
design with 2 arms,
catechins). ingestion. CAD including CRP.
CRP in the high-risk group >3 mg/L
was significantly decreased by 53.4%
9 g (3 cups of black tea) daily and 41.1% in men and women,
Bahorun et al. [56] n=232 Susceptible to 12-week randomized followed by a 3-week wash-out respectively. Tea supplementation-
CRP.
Mauritius ischemic heart disease. controlled study. (with control group consuming associated decrease in plasma uric
hot water). acid and CRP levels may benefit
humans at high risk of CV events and
may augment drug therapy.

Abbrevations: ACE: Acetylcholinesterase, BMI: Body Mass Index, BP: Blood Pressure, BTP: Black Tea Polyphenols, CACs: Circulating Angiogenic Cells, CRP: C-Reactive
Protein, CV: Cardiovascular, HDL; high-Density Lipoprotein, LDL: Low-Density Lipoprotein, MetS: Metabolic Syndrome, NO: Nitric Oxide, SOD: Sodium Oxide Dismutase,
TAC: Total Antioxidant Capacity.
Table 4: Tea and cardiovascular disease outcomes (RCTs only).

Measure of cardiovascular Strength and amount of evidence References

disease
Blood Pressure Strong evidence from meta-analysis that long-term consumption (<12 weeks) and Greyling et al. [20]; Liu et al. [21]; Yarmolinsky et
drinking 4-5 cups tea (green and black) daily could reduce SBP and DBP, especially al. [19]; Hartley et al. [8].
those with blood pressure in pre- and hypertensive ranges.
Emerging meta-analytical evidence that sour tea may reduce SBP and DBP. Serban et al. [25]
Growing evidence from RCTs that drinking 2-3 cups black tea may reduce SBP and Grassi et al. [28]; Hodgson et al. [29]; Hodgson
DBP. et al. [31]
Emerging evidence (3 RCTs) showing that sour tea may reduce BP, especially Kafeshani et al. [27]; Mozaffari-Khosravi et al.
amongst type 2 diabetics. [30]; Mozaffari-Khosravi et al. [33]
One RCT showed that brewed hibiscus tea daily significantly lowered BP amongst McKay et al. [32]
pre- and mildly hypertensive adults.
Cholesterol and lipids Strong meta-analytical evidence indicates that green tea and its catechins may have Yuan et al. [36]; Khalesi et al. [6]; Onakpoya I et
beneficial effects on total cholesterol and LDL reduction. al. [7]; Kim et al. [37]; Zheng et al. [38]
Meta-analytical evidence for black tea is mixed with subjects with higher cardiovascular Zhao et al. [34]
risk appearing to have most benefit.
Longer-term trials imply that black tea may reduce triglyceride levels, alter body fat Ashigai et al. [40]; Bohn et al. [6]; Bahorun et al.
distribution and increase fat excretion. [44]
Emerging evidence from RCTs that chamomile and goshi tea could improve blood Ishida et al. [39]; Rafraf et al. [41]
lipid profiles.
Cardiovascular function Strong meta-analytical evidence indicates that drinking green tea (1-3 cups daily) Pang et al. [45]; Tang et al. [46]
could reduce MI and stroke risk. Other works shows 2-3 cups of green or black tea
daily could improve endothelial function.
Growing evidence from RCTs that black tea could improve flow-mediated dilation and Grassi et al. [48]; Schreuder et al. [49]; Grassi et
levels of circulating angiogenic cells. al. [53]
Inflammation Meta-analytical evidence looking at tea intake in relation to markers of inflammation Maghsoumi-Norouzabad et al. [54]; Mahmoud et
is lacking. al. [55]; Koutelidakis et al. [43];
Four RCTs show that certain patient’s groups – type 2 diabetics, those with coronary Bahorun et al. [56]
artery/ ischemic heart disease or knee osteoarthritis could benefit from tea drinking
(black, green and burdock root tested).
Table 5: Summary of the results of systematic review of tea and cardiovascular disease.

findings for black tea appear reveal that more research is needed. One
paper showed favourable effects on serum LDL cholesterol, particularly
amongst those with elevated cardiovascular risk [34]. Another reported
no effects in relation to total cholesterol, LDL or HDL concentrations
[35].
Eight RCTs examined the effects of tea interventions on cholesterol
levels, lipid profile and distribution [6,39-44]. In most studies 3 to
5 cups of tea were ingested daily [6,41,42,44]. One trial comprised
of two 2-week treatment periods found that amongst borderline
hypercholesterolemic subjects 5 cups of tea daily did not alter lipid
profiles [42]. A longer 12-week trial providing 3 cups (each 200 ml)
of black tea infusate to normal healthy adults showed that triglyceride
levels reduced by 35.8%, and LDL/HDL plasma cholesterol ratio
reduced by 16.6% [44]. A post-ingestion study discovered that serum
triglyceride levels significantly rose 3 hours after breakfast with water
but not with tea [43].
Regarding lipid distribution one trial found that drinking black tea
over 3 months significantly reduced waist circumference and waist-to-

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ISSN: 2155-9600 Volume 8 • Issue 5 • 1000724
Citation: Etheridge C, Bond T, Derbyshire E (2018) Effects of Tea Consumption on Measures of Cardiovascular Disease: A Systematic Review of
Meta-Analysis Studies and Randomised Controlled Trials. J Nutr Food Sci 8: 724. doi: 10.4172/2155-9600.1000724
hip ratio indicating improved body fat distribution [6]. A small trial
comprised of two 10-day intervention periods found that the ingestion
of black tea polyphenols (55 mg as a beverage) three times daily
increased faecal lipid excretion [40]. Other work using Goishi tea (122
mg polyphenols) found this to increase HDL cholesterol and reduce
elevations in triglycerides, especially amongst those with a BMI <25
kg/m2 after 12 weeks of drinking this [39]. Amongst patients with type
2 diabetes chamomile tea (3 g/150 ml hot water) thrice daily after meal
over 8 weeks significantly lowered total cholesterol, triglyceride, and
LDL levels compared to a control [41]. The overall quality of studies
was good with all seven RCTs having a Jadad score of 3 or above. One
drawback was that 5 of these did not provide a detailed breakdown of
blinding methods used.
Cardiovascular function
Three meta-analysis articles focused on inter-associations between
tea drinking and cardiovascular function [45-47]. One meta-analysis
focused on green tea concluding that those drinking 1-3 cups per day
contributed to reduced myocardial infarction risk (OR=0.81, 95%
CI: 0.67-0.98) and stroke (OR=0.64, 95% CI: 0.47-0.86) compared
to those who drank <1 cups/day [45]. Pooled analysis from 18
cohorts demonstrated that a one cup per day increment of green tea
consumption lowered the risk of CVD mortality by 5% [46]. Other
work found moderate consumption of black or green tea (2-3 cups;
500 ml) to enhance endothelial-dependent vasodilation which could
provide a mechanistic explanation for the reduced risk if cardiovascular
events observed amongst tea drinkers [47].
Six RCTs focused on aspects of CV function [48-53]. A small
8-day trial providing black tea (150 mg polyphenols) twice daily
noted improvements in circulating angiogenic cells (CACs) and flow-
mediated dilation (FMD), with a maximal response 2 hours after
ingestion [48]. A 7-day trial of 20 healthy subjects drinking 3 cups black
tea per day also observed improvements in FMD with this appearing
to relate to a direct effect of the tea on the endothelium [49]. Similarly,
amongst 19 healthy men drinking black tea twice daily over 5 1-week
periods showed that the variety of tea providing 800 mg flavonoids
significantly improved FMD and reduced peripheral arterial stiffness
compared with the control [53].
A small 8-week RCT showed that green tea (4 cups/day) significantly
reduced plasma serum amyloid alpha; an independent CV disease risk
factor, in obese subjects with metabolic syndrome [50]. Authors from
a separate study concluded that green and Rooibos teas may exert their
CV effects by inhibiting ACE activity [52]. Other work showed that
high versus low catechin green tea had no effect on CV risk factors [51]
although this was conducted on healthy adults. Regarding the quality
of trials one lacked rigor [52] but the remaining trials were adequately
designed.
Inflammation
Focused meta-analytical evidence on tea drinking in relation to
inflammation and related markers is lacking. Four trials conducted
some research in this field [43,54-56]. With regard to black tea a 12-
week trial showed that three cups (600 ml) daily increased regulatory
T-cells and reduced pro-inflammatory cells amongst patients with type
2 diabetes [55]. A large Mauritian trial found that CRP levels reduced
by 53.4% in men and 41.1% in women at high risk of ischemic heart
disease drinking 3 cups of black tea daily over 12-weeks [56].
One small post-ingestion trial observed no links between green
tea consumption and CRP levels [43]. However, amongst 36 patients
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Page 7 of 9
with knee osteoarthritis drinking three cups of Burdock root tea daily
(2 g/150 ml boiled water) over 42 days appeared to aid and significantly
reduce markers of inflammation (Interleukin-6, high sensitivity-C-
reactive protein) and improved levels of oxidative stress [54]. Further
adequately designed trials are needed. Only one trial focusing on
inflammation was found to be of suitable quality according to the Jadad
scale.
Discussion
A summary of the results from this review is given in Table 5.
There has been a significant upsurge in the number of scientific articles
studying the role of tea in human health [5] (2097 related publications
in the last 10 years; PubMed search) – this includes its role in relation
to cardiovascular well-being. Tea is one of the most popular and cost-
effective beverages consumed after water - renowned for its health
promoting properties since ancient times [3]. Alongside this, the
market and evidence-based for tea forms other than black and green
tea is growing. This is reflected in the present review with evidence
for chamomile, sour, hibiscus, goishi and rooibos tea in relation to
cardiovascular wellbeing emerging (Table 3).
In relation to measures of cardiovascular health strongest positive
effects relate to black and green tea, most consistently in relation to
reduced systolic and diastolic pressure [8,19-24]. The totality of the
evidence indicates that drinking 4 to 5 cups of black and green tea
daily in the longer term (for more than 12 weeks) could help to reduce
systolic and diastolic blood pressure [20,21] particularly amongst
those at risk of high blood pressure [19]. Given the high prevalence of
hypertension in the UK and worldwide these findings have important
public health implications [31]. For example, a large proportion of
the general population have blood pressure levels within the ranges
included in trials i.e. at increased risk of hypertension making results
particularly applicable [29,31].
Next, evidence was strongest in relation to cholesterol and lipid
levels. Green tea appears to be more strongly related to reduced
total and LDL cholesterol, as evidenced by a large number of meta-
analytical publications [22,23,36-38]. For black tea those with a higher
cardiovascular risk appear to have more benefit [11] with indications
from RCTs suggesting that black tea could reduce triglyceride levels,
alter body fat distribution and increase fat excretion [6,40,44]. For
black tea there is evidence that this can improve FMD and exhibit
vascular protective properties that could be of clinical relevance
[48,49,53]. Although these effects appear to be modest they could be
of importance for cardiovascular health at the population level due
to the widespread habitual consumption of tea and high prevalence
of cardiovascular risk factors. The number of studies looking at tea in
relation to inflammation was small but indicated a positive effect. Some
findings suggest that certain populations may benefit such as those with
type 2 diabetes [55] or ischemic heart disease [56]. Further studies on
healthy populations are needed to better understand how tea drinking
could affect inflammation.
In terms of mechanisms, reductions in CVD risk by tea may be
attributed to high levels of polyphenols which both green and black tea
contain [8]. Polyphenols (as found in tea) when taken in adequate doses
can have a positive effect on the prevention of cardiovascular risk and
lipid oxidation [57]. These can also increase the endothelial synthesis
of nitric oxide yielding vasoprotective effects [58]. It has also been
proved that these compounds can alter hepatic cholesterol absorption,
triglyceride biosynthesis and lipoprotein secretion, the processing of
lipoproteins in plasma, and inflammation [59]. Bearing this in mind the
Volume 8 • Issue 5 • 1000724
Citation: Etheridge C, Bond T, Derbyshire E (2018) Effects of Tea Consumption on Measures of Cardiovascular Disease: A Systematic Review of
Meta-Analysis Studies and Randomised Controlled Trials. J Nutr Food Sci 8: 724. doi: 10.4172/2155-9600.1000724
different dosages of polyphenols used in trials could have contributed
to variations in study findings. It would be worth deciphering ideal
‘optimal doses’ of polyphenols that could influence specific aspects of
health such as cardiovascular wellbeing. Tea polysaccharides (TPS)
– a group of heteropolysaccharides bound with protein are another
component worthy of further investigation [60]. TPS are thought
to possess bioactive antioxidant and anti-inflammatory properties
with could influence measures of CVD [60]. Finally, it should also be
considered that whilst many biologically active compounds in tea have
been identified many unidentified compounds remain which could
also possess bioactive properties [4].
All the papers reviewed were either meta-analytical or RCTs which
makes findings stronger than if they were cross-sectional. It was a
strength that the present article focused on the use of teas per se rather
than tea extracts. This also makes the findings more applicable to the lay
population and lowers costs for the public domain. Regarding future
research several suggestions have been put forward. Meta-analysis
papers need to ‘separate out’ green and black tea (and indeed emerging
tea forms) so their individual effects can be better deciphered. There
is evidence that various types of teas could act synergistically which
could have health benefits to humans [7]. However, their individual
effects first need to be clearly understood before cumulative effects
are studied. It is important that future RCTs should be long enough
in duration to be relevant to public health. Smaller studies tend to be
less methodologically robust and are more likely to be conducted in
selected populations where they can report larger beneficial effects than
larger trials [61,62]. Where studies lacked conclusive results, this may
have been due to their short duration, small sample sizes or inadequate
tea (polyphenol) dosing regimens. The results of the present review
need to be interpreted with this in mind.
Conclusion
Moderate intakes of tea (black and green) appear to be linked with
blood pressure reductions at around 4 to 5 servings per day. Green tea
seems to benefit the lowering of total and LDL cholesterol. Daily tea
consumption also appears to have generic extended benefits including
improved vascular function and reduced inflammation. Based on the
evidence collated it seems plausible that tea consumption could be
recommended to the general population or to patients as a strategy
to reduce cardiovascular risk. These benefits largely appear to be
attributed to the synergistic effects of tea phenolics coupled with its
flavonoid elements.
Disclosure
The views expressed are those of the authors alone and personnel
from the UK TEA & INFUSIONS ASSOCIATION (UKTIA) had no
role in writing this review.
Acknowledgement
The authors received funding provided by the Tea Advisory Panel which is
supported by an unrestricted educational grant from the UK TEA & INFUSIONS
ASSOCIATION (UKTIA), the trade association for the UK tea industry. UKTIA plays
no role in producing the outputs of the panel. Independent panel members include
nutritionists, biochemists dietitians and doctors. See www.teaadvisorypanel.com.
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